PR 27 denial code

What PR-27 means

PR-27 means the payer’s records show the patient’s coverage ended before the date of service. The claim reached the right company, the member existed, but the policy was no longer in force on the day of the visit. Group code PR assigns the balance to the patient, and in most cases that is where it belongs; someone whose policy has terminated is self-pay for that date unless replacement coverage was active.

Its sibling code is PR-26, the same problem in reverse: service before coverage began. Work both the same way, by pinning down exactly what coverage existed on the date of service.

Common causes

1. Employment ended. Group coverage typically terminates with the job or at the end of that month, and patients often do not realize it immediately.
2. Missed premium payments: individual and marketplace plans terminate for non-payment, sometimes retroactively to the end of a grace period.
3. Plan changed at open enrollment: the patient moved to a new plan January 1 but presented the old card.
4. Medicaid redetermination removed the patient from the rolls.
5. Dependent aged out of a parent’s policy.
6. Patient moved to a Medicare Advantage plan: traditional Medicare claims for those patients deny because the MA plan holds the coverage; that scenario also produces CO-22-style coordination issues.
7. Simple mistake: wrong date of service keyed on the claim, making a covered visit look post-termination.

How to fix and resubmit

1. Confirm the date of service on the claim matches the encounter. Fix and resubmit if it was keyed wrong.
2. Run eligibility (270/271 or payer portal) and record the termination date the payer holds.
3. Ask the patient. At this point you are looking for the replacement coverage: new employer plan, COBRA election, a spouse’s plan, Medicaid, or a Medicare Advantage enrollment.
4. If replacement coverage existed on the service date, bill that payer promptly. Keep the PR-27 remittance; if the new payer raises timely filing, the denial from the original payer documents why the claim arrives late, and most payers accept that with an appeal.
5. If the patient elected COBRA retroactively, the old plan may reinstate the coverage period; re-verify and resubmit to the original payer once reinstatement shows.
6. If no coverage was active, transfer the balance to self-pay. Call or message the patient before the statement goes out, explain the termination date, and offer a payment plan if your policy allows. An appeal to the payer is pointless; termination dates are enrollment facts.

How to prevent it

• Verify eligibility at scheduling and again at check-in for every visit. Termination between booking and visit is common; a same-day 271 catches it.
• Read the eligibility response for termination dates rather than just an active/inactive flag.
• Re-verify all recurring patients each January and after Medicaid redetermination cycles in your state.
• Ask a standing registration question: “Any changes to your insurance or employment since your last visit?” It is low-tech and catches what the card cannot show.
• Trend PR-27 denials by month. Spikes in January and July usually point to plan-year turnover your front end is not catching.